Better Nutrition In Early Life Could Give India 3.17 Million More Graduates

Mount Abu (Rajasthan): Ensuring supplementary nutrition for children in the 0-3 years age bracket could raise the number of graduates in India by 3.17 million, according to new research.

Children who received extra nutrition through government-run programmes from the time they were in their mothers' wombs until age three were 11% more likely to acquire a graduate degree than those who received them between ages three and six, according to a new study published on January 1, 2018, in the Journal of Nutrition.

These early life beneficiaries of supplements, supplied through the Integrated Child Development Services (ICDS), were also 9% more likely to complete secondary education, 5% more likely to be employed or enrolled in higher education as young adults, and 6% more likely to have remained unmarried until the age of 25, said the study.

Adequate nutrition during what is called the 1,000-day-window-of-opportunity--the time between pregnancy and a child's second birthday--is known to protect children against stunting and cognitive deficiencies. Scientists who followed the lives of children and mothers at anganwadis--government centres that offer health and nutrition services--found positive health impacts persist till adolescence.

When anganwadi children aged 13-18 were studied, it was found that early life beneficiaries were 14 mm taller, with healthier cardiovascular systems, more likely to be enrolled in school and about a grade ahead of others, earlier studies had shown. The new study offers conclusive evidence that adequate nourishment to unborn babies and infants creates benefits that enhance their education and employment prospects in later life.

With the education benefit of early-life nutrition extending to college, the researchers estimated that such daily exposure could potentially increase India's college graduates from 7.5% of the country's 73.8 million 20-24-year-olds to 11.8%. An increase in the college graduation rate, in turn, would deliver significant economic gains from higher wages.

This would be a significant economic achievement for a country with one in four of the world's 156 million stunted under-five-year-olds. In 2016, it was estimated that growth faltering among India's under-five-year-olds would cost $37.9 billion in future, through lost schooling and economic productivity.

By delaying the age at marriage of beneficiaries, better nutrition in the crucial first 1,000 days of life would also foster a new generation of healthier and brainier children. A single year's delay in marriage lowered the chance of a woman giving birth at home by 2.2%, increased the breastfeeding rate by 5.5% and the chance of children being fully vaccinated by 4.6%, according to this 2017 Journal of Development Economics study.

Poor supervision keeps ICDS food quality, coverage low

The ICDS is a 33-year-old programme, so the question is, why isn't India already experiencing these gains?

"Quality is the biggest factor for the potential educational gains not being experienced so far," Arindam Nandi, the lead author of the study and a researcher at the Tata Centre for Development, University of Chicago, and the Centre for Disease Dynamics, Economics & Policy, told IndiaSpend.

"The base study conducted between 1987 and 1990 was done in a highly controlled setting, with close oversight of service and meal quality," Nandi said.

Anganwadi workers involved in the study, conducted in villages near Hyderabad, prepared a blend of corn and soya in soybean oil under strict supervision so as to provide 500 kcal of energy and 20-25 grams of protein to pregnant women and half of those amounts to the infants.

"In contrast to that tightly controlled scenario, the real life conditions in anganwadis across the country are, and always have been, vastly different, keeping the quality and coverage low," said Nandi.

A network of 1.36 million anganwadis implements the ICDS' supplementary nutrition programme. This decentralised delivery approach is necessary to reach out to far-flung communities across the country. However, this spread also makes supervision challenging.

"Because the programme (ICDS) is administered very locally (at the village), improving quality and coverage is a very difficult task," said Nandi.

Where the local supervision is good, the food quality is better and the uptake of the service is higher.

For instance, about six in 10 lactating mothers and pregnant women and five in 10 children aged 6 months to 6 years registered with an anganwadi in a Delhi slum used supplementary nutrition, according to a 2017 study. This was higher than the 40% minimum expected uptake from the service, an outcome that the study co-author attributed to "the quality of the cooked meal".

"The Delhi government's centralisation of the cooking and strict monitoring of anganwadis has helped maintain the quality," Jitendra Kumar Meena, co-author of the study and assistant professor, department of community medicine, Geetanjali Medical College & Hospital, Udaipur, told IndiaSpend.

However, Meena, who visited anganwadis in Haryana, Rajasthan, Punjab and Uttar Pradesh, said food quality is poor in anganwadis that are not closely monitored.

"Poor quality of food is a big reason for the low coverage of many anganwadis," he said.

Across India, less than half of India's needy children and women use the supplementary nutrition service of the anganwadis, according to a 2013-14 report.

Government authorities are apparently deliberating the poor quality of food, but no solution has been made public as yet.

"A committee is looking into the issue of poor quality of food served by anganwadis," K B Singh, director, ICDS, ministry of women and child development, told IndiaSpend.

Complaints about anganwadi nutritional supplement services also include irregularities in distribution, which individual studies suggest are also a local phenomenon caused by poor supervision.

Interruptions in distribution were reported by more than half of the 130 anganwadis in 12 districts of Gujarat and the union territory of Diu surveyed in a 2016 study. In contrast, Meena found the anganwadi in Delhi's urban slum had received regular supplies.

10,000 new anganwadis for Bihar, but services across India need financial push

Poor infrastructure and services were pointed out in a 2013 report of the Comptroller and Auditor General (CAG) of India that described anganwadi centres and the ICDS scheme as a "failure".

"Quality services provided to the beneficiaries were seriously compromised as basic amenities like toilet, drinking water, kitchen, utensils, etc. in anganwadi centres were missing," read a CAG review of the state of the ICDS in Bihar in 2017. "In addition, 72 per cent of the functional AWCs did not have their own building in Bihar."

"To turnaround the ICDS, and reduce variations in quality and coverage across the nation, the programme probably needs a huge financial push to build new anganwadis and improve the infrastructure of the existing ones, to increase per meal budget, worker salaries and incentives, and reduce systemic inefficiencies," said Nandi.

India's most populous states Bihar, Uttar Pradesh, Jharkhand, Chhattisgarh and Madhya Pradesh are most in need of new anganwadis: They have populations where more than 40% of children are stunted. Also, in these states the existing infrastructure is stretched beyond the 40 children/centre limit referred to in a 2012-13 CAG report.

In Bihar, for instance, a single anganwadi was providing supplementary nutrition to 193 children in 2014, nearly three times the national average of 68 children per centre. In Uttar Pradesh, the corresponding figure was 101.

In Bihar, this overload can be traced to 20% of the sanctioned anganwadis not being operational as on September 30, 2017.

This may soon change.

"India has 13.60 lakh operational anganwadis as against the sanctioned 14 lakh. Of the 40,000 more anganwadis to be opened, 10,000 are expected to be launched in the current year, mostly in Bihar," Singh told IndiaSpend.

Quality rests on workers who are poorly paid, lack motivation

In recent months, India has seen widespread protests by anganwadi workers for a wage hike. Anganwadi workers and helpers are currently being paid a monthly honorarium of Rs 3,000 and Rs 1,500 respectively by the Centre.

The central government last enhanced the honorarium of anganwadi workers and helpers on April 1, 2011, IndiaSpend reported on February 23, 2018.

Honorariums are often paid late. In a survey of six states, close to 40% of anganwadi workers had to use their personal money to run their centres and 35% of them had not been paid on time, according to the Progress of Children Under Six 2016 report.

"Poor infrastructure and low wages tell on the workers' motivation levels and sometimes, this encourages corruption," said Meena.

Pilferages of food meant for distribution to malnourished children is common and recognised as a problem by the government. A suggestion by the Prime Minister's Office last year proposed bar code technology to check this leakage.

Acting on this, the women and child development ministry has introduced smartphones for the workers. During a pilot study in six states--Andhra Pradesh, Madhya Pradesh, Bihar, Chhattisgarh, Jharkhand and Rajasthan--workers at 62,000 anganwadi centres were given smartphones which helped replace the 11 registers needed to prepare job charts, mark children's attendance, upload photos of meals prepared, track services (such as how many children were provided food, how many were weighed, etc.) and monitor the progress of malnourished children.

"Technology will usher in real-time monitoring of the anganwadi services," said Singh.

"With the ability to identify and monitor the progress of every malnourished child, and the provision for SMSs to be automatically generated as long as the child continues to be cause for concern, we expect to see improvement in the health outcomes of the anganwadi service," he said.

Pilferages would be checked by requiring the worker to scan a barcode on the packet of take-home ration, prior to distribution, and add that information to the beneficiary profile maintained on a database accessible by supervisors.

Mothers aware of anganwadi service but not of early-life nutrition needs

So far, government messaging has helped ensure that nine in 10 mothers of young children or pregnant women knew about the supplementary nutrition service of anganwadis in 2013-14. However, considering that only 40-50% of mothers and pregnant women actually availed the service, Meena suggested a shift in the focus of the messaging.

"The government has overemphasised the supplementary nutrition component of the ICDS as against promoting the comprehensive package of ICDS services," he said. What happens then is since not every family is interested in the additional food, the supplementary nutrition coverage stays low.

"More children could avail the nutrition if their parents saw the entire value being provided by the anganwadi--nutrition plus health plus education," he added.

A family's low interest in the supplementary nutrition could be a reflection of low awareness of its benefits, and of the fact that you cannot make up for poor early life nutrition.

"Indian policies reflect the 1,000-day period very well, through several programmes aimed at health, nutrition, and nurturing of young children, but it is probably time to also raise awareness among the public of this crucial time of development so that these free or subsidised programmes are accessed fully," said Nandi.

(Bahri is a freelance writer and editor based in Mount Abu, Rajasthan.)

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